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Diabetic gastroparesis is a complication of long-term diabetes characterized by delayed gastric emptying that is not associated with mechanical obstruction. Risk factors are inadequate glycemic control and obesity. Symptoms typically include nausea, vomiting, abdominal discomfort, and early satiety. Diabetic gastroparesis is a diagnosis of exclusion and is confirmed by scintigraphic gastric emptying. The mainstay of treatment is conservative management with glycemic control, dietary modifications, and avoidance of medications and substances that delay gastric emptying. Prokinetic agents may improve gastric emptying, whereas antiemetics can provide symptom relief. Patients with refractory symptoms may require surgery, gastric electric stimulation, or parenteral feeding.
See also “Diabetic neuropathy.”
- Poor glycemic control, sustained hyperglycemia > 200 mg/dL → neuronal damage → impaired neural control of gastric function (e.g., interstitial cells of Cajal dysfunction, abnormal myenteric neurotransmission, smooth muscle dysfunction, vagal dysfunction) → antral motor coordination and function abnormalities (↓ antral contractions, pyloric spasms, abnormal antroduodenal contractions) → delayed gastric emptying
- Abnormal small bowel motility → ↑ or ↓ gastric compliance → delayed gastric emptying
- Autonomic neuropathy → abnormal gastric electrical activity and visceral perception
- Perform clinical evaluation to exclude differential diagnoses of gastroparesis.
- Obtain upper endoscopy to exclude mechanical obstruction. 
- Perform confirmatory testing to observe delayed gastric emptying.
- HbA1c: to assess glycemic control
- Depending on clinical features, obtain additional studies to rule out differential diagnoses of gastroparesis, including:
- Stable isotope breath test 
- Delayed gastric emptying is confirmed if studies show > 10% gastric retention after 4 hours. 
- Alternative causes of gastroparesis
- , e.g.: 
- Other disorders
The differential diagnoses listed here are not exhaustive.
- All patients
- Initiate nonpharmacological measures to improve gastric emptying.
- Refer to gastroenterology.
- Persistent symptoms: Start pharmacological treatment.
- Refractory disease: Consider surgical referral or gastric electric stimulation.
Pharmacotherapy should be offered as a short-term treatment for diabetic gastroparesis; long-term use of medications is associated with adverse effects. 
Nonpharmacological management 
- Optimize treatment of diabetes to achieve .
Initiate dietary modifications in consultation with a nutritionist. 
- Small, frequent meals
- Low in fat and fiber
- Small particle size 
- If possible, prescribe alternatives for patients taking medications associated with delayed gastric emptying. 
- Avoid substance use (e.g., tobacco, alcohol, cannabinoids). 
- Acupuncture may improve gastric emptying and provide symptomatic relief 
- Used to improve symptoms and gastric emptying
- First line: metoclopramide
- Improve symptoms (nausea, vomiting) but do not improve gastric emptying.
- Options include (e.g., ondansetron) and (e.g., aprepitant)
Management of refractory diabetic gastroparesis
- placement: may be performed for patients requiring enteral feeding 
- Venting gastrostomy: may be used for relief of symptoms (e.g., bloating, vomiting) 
- Gastric peroral endoscopic
- Other procedures (rarely performed): 
Gastric electric stimulation (GES)
- Provides high-frequency electrical pulses to the stomach through leads that are implanted into the stomach wall to enhance gastric emptying 
- Evidence to support its use has been mixed.